Basic Information
| Provider Information | |||||||||
| NPI: | 1093169526 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN FERNANDO VALLEY COMMUNITY MENTAL HEALTH CENTER, INC. | ||||||||
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| OtherOrganizationName: | SFVCMHC, INC.-MILESTONES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16360 ROSCOE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914061219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014830 | ||||||||
| FaxNumber: | 8187853446 | ||||||||
| Practice Location | |||||||||
| Address1: | 16650 SHERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914063782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014830 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2016 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | RYDER | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8189014830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | D0591483 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.